Pediatric Integrative Medicine In the Office. Matthew Hand DO Director, Pediatric Nephrology and Integrative Medicine Elliot Health System

Transcription

1 Pediatric Integrative Medicine In the Office Matthew Hand DO Director, Pediatric Nephrology and Integrative Medicine Elliot Health System

2 IM/CAM in Pediatrics Goals What is IM/CAM Prevalence/Epidemiology Things that I get called about IM approach to headaches ADHD supplements Colic Resources What are we doing to change the health care of children

3 My initial thoughts Healing vs. curing Is there research? Cross over in modalities Not clearly toward the disease but more the experiences/life of the patient (sleep, wellness, anxiety etc) Many names, many tools, don t get frustrated Opening the mind You can t go back this isn t complementary and alternative medicine, it is just good medicine

4 What is IM Broad Categories Conventional Med Nutrition/Diet Exercise/Physical Activity Whole systems (TCM, Ayurveda, Naturopathy, Homeopathy) Botanical med Energy Medicine (Reiki, Healing touch, Qi Gong etc) Supplements Spirituality Manual Medicine (OMM, Chiropractic, Massage, PT, Zero balancing, reflexology etc) Mind-Body Medicine (Hypnosis, Biofeedback, Guided imagery, Creative therapy etc)

5 Treatment Approach Multi-level approach First: Dealing with the acute illness, IE what can we do to help treat the disease or manifestation of the disease right now. Second: Decreasing long term aspects of the disease, IE preventing flares, decreasing long term needs/dosages of meds Third: Change the medical model from disease to WELLNESS. Every patient has more wellness than disease. We all get something, it is what we do with it view it as a gift. Fourth: Helping to decrease/manage med side effects. IE sleep issues with steroids, liver toxicity etc.

6 Basic Principles Nutrition Exercise Stress Reduction Mind, Body and Spirit Approach Underneath all treatment modalities, these are the basic principles for all patients. If we can simply do these, we will improve the patients quality of life. Complexity vs. reduction thought. Wellness vs. Disease model

7 Who is using it and what are they using In the US, (1997)~1/3 of all adults use CAM Visits to CAM providers 1990:420 million, 1997:629 million (up by47%) 1997 estimated 21.2 billion dollars ~12billion out of pocket Billion spent out of pocket to treat pain, 33.9 total out of pocket for all issues (NIH) Billion dollars spent on botanicals and supplements alone More recent estimates~40-62% adults using CAM (40% NIH) Higher levels of education and economic status

8 In Children: ~12-30% of healthy children seen in outpt clinics use CAM (NIH, Kemper) >50% of children with chronic, recurrent or incurable illness use CAM ALMOST ALL STILL CONTINUE WITH WESTERN TREATMENTS! For specific conditions: For Asthma: 33-89% pediatric patients using CAM to some degree. For GI issues, studies with >50% of all patients using some form of CAM.

9 CF 77% using some form of CAM When prayer not included, 65% Most common was biologicals (ie herbs, supplements), next mind-body, manipulation, and then whole body systems 85% of those using herbs felt it helped, no overt side effects and ~1/2 had told their provider. 95% stayed with concurrent medical treatment

10 Research Major issue when trying to evaluate and discuss CAM in Western medicine Commonly stated There s no data or the data is all bad As of 2002, there were >1400 randomized controlled studies regarding CAM therapies. ~50 systemic reviews. In 2005, two reviews in J Clin Epid, showed that the quality of RCT in CAM and the reviews were equal to or exceeded that of conventional medicine.

11 In addition: 2005 Review noted publication bias in CAM was opposite that of conventional medicine. Negative studies are more likely to be published and positive studies are more likely to be published in foreign medical journals. Difficulties: Marked variation in modalities Differences in diagnosis Individualized care, particularly with whole systems. Consistency with treatment therapies (doses/concentrations, compliance, practitioner etc)

12 Functional Abdominal Pain Therapy Recurrent Abdominal Pain: -Address Diagnosis -Address Pathophysiology -Work-up if red flags present -Normalize lifestyle -Fiber therapy, bulking agents -Medications: anti-spasmodics, H2RA, PPI, anti-emetics, motility, bacterial overgrowth From Mark Integlia MD, Dir. Peds GI

13 Complementary and Alternative Therapy Use of Different CAM Therapies CAM Therapy Patients (N=278); n (%) Phytotherapy 128 (46) Supplements 100 (36) Manual therapies 66 (24) Homeopathy 61 (22) Energy Medicine 48 (17) Traditional Chinese Medicine 30 (11) Bioelectrical therapies 22 (8) Others (mind-body, philosophical, rest group) 35 (13) Vlieger et al. Pediatrics. 2008;122; e446-e451. From Mark Integlia MD, Dir. Peds GI

14 Complementary and Alternative Therapy Mind-Body Therapy: *Cognitive Behavioral Therapy (CBT) *Gut-directed Hypnotherapy (HT) *Biofeedback *Guided Imagery Botanicals: *Peppermint Oil *Ginger Biologics: *Probiotics From Mark Integlia MD, Dir. Peds GI Acupuncture Yoga

15 Complementary and Alternative Therapy CBT: Children and caregivers are taught: -reframe perception of pain -reward well behavior -establish contingency plans for management of pain -attempt to ignore pain behavior -use of positive self-talk, relaxation and imagination -56% pain-free initial response with 75% pain-free at 6 months Sanders et al: J Consult Clin Psychol. 1994;62: Groups taught CBT: 72% pain-free post intervention Humphreys et al: J Pediatr Gastroenterol Nutr. 2000;31: % decrease in pain scores and 30% decrease in absenteeism Robins et al: J Pediatr Psychol. 2005;30: From Mark Integlia MD, Dir. Peds GI

16 Complementary and Alternative Therapy Hypnotherapy: Many similar characteristics to CBT -An explanation of the physiology of pain -An emphasis on non-pain behavior -Relaxation and mental imagery -Major difference: specific suggestions for relief of pain via therapist RCT: comparing effectiveness of HT vs. standard medical therapy (SMT) -53 patients; age 8-18 years with FAP (n=31) or IBS (n=22) -HT: 6 session over 3 months -SMT: standard medical care and 6 sessions supportive care -pain intensity, frequency and associated symptoms were scored post therapy, 6 mo and 12 mo. Vlieger et al. Gastroenterology. 2007;133:

17 Complementary and Alternative Therapy post 6mo 12mo SMT HT SMT HT SMT HT Improved 32% 26% 17% 22% 29% 11% Remission 12% 59% 17% 71% 25% 85% P<.001 between treatment groups at all end points From Mark Integlia MD, Dir. Peds GI Vlieger et al. Gastroenterology. 2007;133:

18 Complementary and Alternative Therapy Biofeedback: -Combines relaxation and mental imagery with visual or auditory feedback of somatic changes -ie: skin temperature, skin resistance, heart rate variability -Especially helpful in modulating autonomic reactivity Guided Imagery: -A form of self regulation in which a state of deep relaxation in induced using progressive muscle relaxation (PMR) -The subject is then guided to actively create images to facilitate resolution of the problem - Differs from hypnosis in that the patient creates their own solution - Especially effective in children due to their ability to have active, creative imaginations From Mark Integlia M Dir. Peds GI

19 Complementary and Alternative Therapy Peppermint oil: Carminative- gas relieving Menthol- component which acts to relax smooth muscle by blocking calcium channels; most products have 44% menthol Also found to have mild topical anesthetic effect In children found to be both safe and effective. Dose: ml per day Forms: enteric coated, peppermint oil soft gels, oil Randomized, double-blind, controlled 2-week trial: 50 children; dose- 1-2, 187mg peppermint oil 3X/day for 2 weeks 76% receiving enteric coated peppermint oil caps with decrease Sx 19% decrease in placebo group Kline et al. J Pediatr 2001;138: From Mark Integlia MD, Dir. Peds GI

20 Complementary and Alternative Therapy Ginger (Zingiber officinale): Root of ginger plant chewed to alleviate nausea- ancient times India- proverb saying that all good is found in ginger Most often used in patients with nausea, dyspepsia, motion sickness Prokinetic action mediated by spasmolytic activity upon Ca++ channels Proven effectiveness in reducing postoperative nausea and emesis Can cause mild abdominal pain in some patients Dosing: 250mg to 1.0 gram; max adult dose of 5 gm per day Ginger is available as a dried or fresh root, tea, powder form, liquid extract, tincture, tablets, capsules, and candied form From Mark Integlia MD, Dir. Peds GI

21 Complementary and Alternative Therapy Probiotics: Ecosystem of gut may differ at times of illness and health Anti-inflammatory effect of probiotics Barrier effect with alteration of mucus layer Treatment- traveler s diarrhea and viral gastroenteritis Lactobacillus and Bifidobacterium studied most often Forms- powder, yogurt, capsules, chewable tablets, freeze-dried powders, wafers and beverages. From Mark Integlia MD, Dir. Peds GI

22 Complementary and Alternative Therapy Probiotics: Lactobacillus rhamonosus GG (LGG) Randomized, double-blind,, placebo-controlled trial receiving either LGG or placebo for 8 weeks; 141children Outcome: overall pain at end of intervention period LGG- significant reduction of frequency and severity of abd pain p<.02 and.001 respectively Week 12: treatment success: 48 children LGG vs. 37 placebo p<.03 Francavilla et al. Pediatrics. 2010;126:e1445-e1452. From Mark Integlia MD, Dir. Peds GI

23 Colic Two good reviews Rosen et al Pedi in review 2009 Rosen : Explore July 2007 Fennel seed oil 125 colicky babies, placebo controlled 65% improvement in treatment group vs 24% control Botanical blends Fennel, chamomile, vervain, licorice, lemon balm Large volume (3 oz/day) 57% improved crying vs placebo 26% Fennel, chamomile, lemon balm, rosemarinic acid, b vit Crying decreased by 85% in treatment group, stat sig vs placebo 200->76 min per day

24 Probiotics 2009 L. Reuteri 100 mill CFUS Compared to simethecone Improvement in one week, increased over 4 weeks, 200min/d->159->51min/d 95% response vs 7% in simethecone group 2010 repeated with placebo only Again stat significant in probiotic group

25 Manual medicine Infant massage Multiple studies showing benefit in infant irritability and bonding Chiropractic 3 studies that I have seen reviewed 2 positive, one not no cracking! OMM Small study without control, improvement

26 Cautions Fennel is sometimes mixed or confused with Star Anise. Chinese anise is viewed as safe, Japanese is not-> neuro toxic. Thus good products are important

27 Headaches in children-my perspective and Impact What is a migraine? Not everything that doesn t fit is an atypical migraine. Suspect there is a big overlap. Prevention=get to the root The pain is very real, even if we can t explain it It may be serving a purpose We all get something, what do we do with it.

28 Continued ~ 10% of population with migraines Women 3X more frequent 112 million bed ridden days $13 billion cost to employers in US Hu et al Arch Int Med X greater school loss days in children with HA

29 Continued 2007 study (Diamond et al Headache) 120,000 households contacted 17.9 % females, 5% males w/ migraine criteria ~ 60% never diagnosed Only 12% using any preventive measures

30 Migraine Chronic daily HA 2-7 % of all children diagnosed with CDH More evidence this may be related to medication overuse. Thus: high priority/emphasis on prevention/triggers IE: stress reduction, sleep, exercise, eating habits Adjunctive nondrug therapies and lifestyle changes round out the requirements for a management plan. The chances for long-term remission or significant improvement are up to 65% Couch JR Curr Treatment Options Neur 2011

31 Triggers ~60% stress 54% sleep issues 39% missed meals Diet (caffeine-withdrawal, food additives etc.) Rothrock et al Headache 2010 Back and neck pain Dehydration» Me for 10 years

32 Acupuncture The best summation Consistent evidence that acupuncture provides additional benefit for treatment of acute migraines. Acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment and has fewer side effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment» Linde et al Cochrane Database Systemic Review 2009

33 Mind Body Therapies Guided imagery, biofeedback, CBT, Hypnosis and can consider certain herbs (anxiolytics/adaptogens) With stress being highest cause of migraine triggers, it would seem to make sense. Be mindful of patients religious and spiritual beliefs. Be aware of prior events that could have a PTSD effect

34 Continued Quite a few studies on various techniques Children very good with this given imagination Best summary: Behavioral treatments possess the most evidence for successful headache management. They have a long history of randomized trials showing efficacy and are considered the first line preventive options. Nicholson et al Curr Treatment Options Neuro 2011

35 Supplements/Botanical Magnesium: early studies showed low mag in migraine sufferers For Prevention: 2 studies (RDBPCT) show effective For children, data on tension type headaches Sun-Edelstein 2009 Grazzi et al Neurol Sci 2007» This had a 70% decrease in HA, 65% decrease in analgesia use and 75% improvement in lessening disability-not controlled

36 Riboflavin (B2)/CoQ10 Riboflavin >50% reduction in migraine headaches Dose: 400 mg a day, biggest tablet is only 100 mg CoQ10 (Ubiquinone) 50% reduction in migraine events (adults 100mg tid) Pediatric study-1-3 mg/kg/day markedly decreased HA and disabilities Need gel or liquid, can be expensive

37 Butterbur Quite good evidence, recently recommended by Amer Acad Neurology RDBPCT (Grossmann et al 2000, Lipton et al Neurology 2004 Open trial in children showing decreased frequency of HA. PA free Commonly studied one is Petadolex 75 mg bid

38 Feverfew 5 RCT, 3 with some benefit Interestingly herbalists report that only fresh plant works which may be part of the problem. Fresh plant can have mouth sores Can have withdrawal, IE rebound HA I have changed my practice

39 Ginkgo New product on the European Market Ginkgo, CoQ10 and Riboflavin. 3 trials good results (second two in kids) D Andrea et al Neurol Sci 2009 Esposito et al Neurol Sci 2011 Usai et al Neurol Sci 2010 Hard to know exactly effective agent but the latter 2 components are low dose.

40 Yoga John, PJ et al Headache patients, randomized to yoga or self care Stat sig decrease in headache intensity, frequency, pain rating index, anxiety and depression scores, medication use Small study from India showed TTH patients with greater decrease in temporalis muscle EMG activity compared to NSAIDS and botulism toxin. Multiple studies show stress reduction, anxiety and mood issues in adults. I like this for stress reduction, alignment, breathwork and regaining control of ones life

41 Manual therapies Osteopathic manipulation, Massage, chiropractic, PT Small studies but positive results Ex Voigt et al J Alt and Comp Med 2011 Interestingly in JAOA OMM vs no OMM, chart reviewed study 50% reduction in cost in patient treatments Mostly meds To me, it is critical, healing touch and trying to remove a primary trigger One of the reasons I went back to active manipulation.

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43 Forty-Three In ancient times, people lived holistic lives. They didn't overemphasize the intellect, but integrated mind, body, and spirit in all things. This allowed them to become masters of knowledge rather than victims of concepts. If a new invention appeared, they looked for the troubles it might cause as well as the shortcuts it offered. They valued old ways that had been proven effective, and they valued new ways if they could be proven effective. If you want to stop being confused, then emulate these ancient folk: join your body, mind, and spirit in all you do. Choose food, clothing, and shelter that accords with nature. Rely on your own body for transportation. Allow your work and your recreation to be one and the same. Do exercise that develops your whole being and nor just your body. Listen to music that bridges the three spheres of your being. Choose leaders for their virtue rather than their wealth or power. Serve others and cultivate yourself simultaneously. Understand that true growth comes from meeting and solving the problems of life in a way that is harmonizing to yourself and to others. If you can follow these simple old ways, you will be continually renewed. Lao Tzu, Hua Hu Ching